Follow the steps to successfully fill out the claim form online.

1. Click the ‘Get Form’ button to obtain the Wellfleet Group Student Insurance Claim Form and open it in the editor.
2. Begin by entering the school name and your personal details. Fill in the student name, member ID number, student address, email, date of birth, city, state, zip, and telephone number. Note that address changes must be made through your plan sponsor.
3. Indicate whether this claim pertains to your dependent by selecting 'YES' or 'NO'. If it does, provide the dependent's name and date of birth.
4. Answer the question regarding any other insurance coverage that may apply to this condition. If applicable, write the name of the insurance company.
5. For health-related claims, indicate whether it is for an annual examination, illness, or injury. If it is for an illness, describe the symptoms and provide relevant dates of the illness and physician consultations.
6. If the claim is for an injury, provide details on how and where the injury occurred, along with any relevant injury dates. Answer questions regarding whether the injury resulted from an auto accident, occurred while working, or happened during a sport.
7. Specify if you have previously sought treatment for the current illness or injury, and describe any past treatments and dates if applicable.
8. Indicate if you were treated by Student Health Services and if you were referred for this condition. Include the name of the provider if applicable.
9. Read the authorization statement carefully and provide your signature along with the date to confirm the truthfulness of the information provided.
10. Once all fields are completed accurately, save your changes. You may then download, print, or share the form as needed.

Complete your Wellfleet Group Student Insurance Claim Form online today to ensure your claim is processed smoothly.